L31 Thoracic Surgery

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Author:
jknell
ID:
202458
Filename:
L31 Thoracic Surgery
Updated:
2013-02-22 12:21:09
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Pulmonary II
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Pulmonary II
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  1. Preoperative Evaluation
    • -assess safety of resection from residual lung fxn standpoint
    • -reduce CV morbidity and mortality (always err on the more conservative side)
    • -evaluate functional capacity and tailor tx to preserve functional status

    • NEED:
    • FEV1 and DLCO >60%
    • Predicted Post-resection FEV1 >40%
    • VO2 max > 10ml/kg/min
  2. DDx of Pulmonary Nodule
    • Malignant
    • -SCLCa
    • -NSCLCa
    • -Metastatic Ca

    • Benign
    • -Infectious
    • -Autoimmune
    • -AV malformation
    • -Pneumoconioses
  3. Surgical Anatomy of the Lungs
    • -Lungs consist of lobes
    • -Lobes consist of segments
    • -LN throughout mediastinum
  4. Malignant
    • -size > 3cm
    • -doubling of volume q2yr
    • -ground-glass nodule
    • -"corona radiata" sign
    • -irregular, multilobulated, spiculated
    • -patient age > 55
    • -stippled calcification
    • -PET positive

  5. Benign
    • -stable in size
    • -diffuse/solid/central/lamellar calcification (healed granuloma)
    • -popcorn calcification (hamartoma)
    • -patient age < 35
    • -PET negative

  6. Workup of Pulmonary Nodule
    • < 4mm
    • -F/U in high risk patients

    • >4-6mm
    • -F/U CT in all

    • >6-8 mm
    • -F/U CT x2

    • >8 mm
    • -F/U CT
    • -PET
    • -biopsy (gold standard, FNA or core)
  7. Lung Cancer Operation
    • -establish/confirm diagnosis
    • -complete resection of tumor
    • -sampling/complete dissection of the LN stations
    • -reconstruction as necessary

    *unless all gross tumor can be encompassed in the resection, the operation should not be undertaken*
  8. Establishment of Diagnosis of Lung Cancer
    • -palpate entire lung (important! catches missed nodules)
    • -frozen sections
    • -FNA or core bx
    • -pleural fluid --> cytology
  9. Lung Cancer Resection Techniques
    • 1. Lobectomy
    • -ideal operation
    • -usually well tolerated
    • -decreased complications vs pneumonectomy
    • -mortality 2% (not much higher in older pts)

    • 2. Bronchoplastic Lobectomy
    • -indicated for endobronchial tumors and densely affixed LNs
    • -local recurrence 17%

    • 3. Bilobectomy
    • -mortality higher than lobectomy but lower than pneumonectomy

    • 4. Pneumonectomy
    • -central tumors that involve mainstem bronchus
    • -bulky tumors that violate the fissures or invade interlobar vessels
    • -mortality 3-15%
    • -carinal pneumonectomy has even higher mortality

    • 5. Segmentectomy
    • -survival worse than lobectomy
    • -appropriate for patients with limited fxnl reserve

    • 6. Wedge Resection
    • -very specific indications
    • -role in metastatic disease but not really in lung cancer
  10. Evaluation of LNs
    • -all accessible enlarged LNs
    • -all PET+ LNs

    • Distinguish between N1 and N2
    • -N1: same side as primary lesion, double digit
    • -N2: same side as primary lesion, single digit
  11. Simultaneous cardiac operation and pulmonary resection
    • -cardiac procedures first
    • -not routinely done
  12. Synchronous Cancers
    • 2/5 Conditions:
    • 1. Anatomically distinct
    • 2. Presence of associated premalignant lesions
    • 3. Absence of systemic mets
    • 4. No mediastinal disease
    • 5. Different ploidy

    • -Only in 1% of NSCLCa
    • -anatomic resection
  13. Stage I Lung Cancer
    -5 year survival ranges from 43-85%

    • Prognostic Factors:
    • 1. Tumor size
    • 2. Cancer type (squamous better than adeno)
    • 3. Location matters (central tumors worse than peripheral tumors)
  14. Stage II Lung Cancer
    • -cT1N1 (33%) has worse survival than pT1N1 (53-56%)
    • -single N1 better than multiple N1
    • -Hilar N1 worse than lobar N1

    • Node Negative Stage II (T3N0)
    • -resection
  15. Stage IIIA Lung Cancer
    • -Mostly N2 disease (vs. T3N1)
    • -N2 disease is usually not resectable
  16. Stage IIIB Lung Cancer
    • -no resection (high mortality, no oncologic value)
    • -exception: carinal tumors
  17. Stage IV Lung Cancer
    • -generally not surgical tx
    • -can improve survival in patients with isolated brain mets
  18. Prognostic Factors Lung Cancer
    • 1. Survival higher in women
    • 2. No significant difference for age groups (young pts present with more advanced disease)
    • 3. Survival worse in African Americans
    • 4. Survival higher in squamous vs adeno
    • 5. Survival higher with fibrosis, infiltration by plasma cells and lymphocytes
  19. Lung Cancer Predictive Tests
    • 1. Complicated
    • -growth regulating ptoeins
    • -apoptosis proteins
    • -cell cycle proteins
    • -angiogenesis factors
    • -etc....

    • 2. Simple
    • -CEA
  20. Thoracic Empyema
    • Simple vs Complex
    • -complex effusion when it develops loculations

    • Light's Criteria for Exudative Effusion
    • 1. Pleural fluid:serum protein ratio > 0.5
    • 2. Pleural fluid:LDH ratio > 0.6
    • 3. Pleural fluid LDH > 200 IU

    • Different Stages of Empyema
    • 1. Exudative
    • 2. Fibrinopurulent (Thin hardened peel)
    • 3. Organizing
  21. Empyema Treatment
    • 1. Drainage of pus
    • 2. Re-expansion of lung
    • 3. Control of pleural space (drains)
    • 4. Augmentation of host immune response by abx

    Surgical treatment preferred for advanced disease (postponing surgery leads to prolonged hospital course)

    • Drainage:
    • -Thoracentesis
    • -Tube thoracostomy
    • -Thoracoscopy (gaining popularity b/c less invasive)
    • -Thoracotomy
    • -Open window thoracotomy and thoracomyoplasty (leave chest open and pack it, may last for months, avoid if possible

    • Complications
    • -pneumothorax
  22. Indications for Lung Transplantation
    • 1. SLT
    • -pulmonary fibrosis
    • -emphysema
    • -primary pulmonary HTN

    • 2. BLT (more common)
    • -septic lung disease
    • -CF
    • -Bronchiectasis
    • -Emphysema
    • -Primary pulmonary HTN

    • 3. HLT
    • -irreversible disease of both heart and lung

    • Most Common Causes of Lung Transplant
    • 1. COPD
    • 2. IPF
    • 3. CF
    • 4. IPAH

    • Trends in Lung Transplants:
    • -increase in BLT
    • -age of recipients has gone up
  23. Lung Transplantation Recipient Selection
    • -age <65
    • -other disease processes
    • -previous surgery
    • -steroids
    • -smoking (absolute)
    • -nutrition
    • -ventilator dependence
    • -timing of transplant
    • -psychosocial factors (absolute)

    Selection criteria are being relaxed
  24. Lung Preservation
    • -HYPOTHERMIA
    • -lung inflation
    • -PGE1 (pulmonary artery vasodilation)
    • -flush pulmonary arteries

    • Rehabilitation
    • -marginal organs can be rehabilitated and checked to see if they will work before they are transplanted
  25. Lung Transplantation Technique
    -Can do on or off bypass (try and do off to avoid complications)

    • -chest opened
    • -inferior and superior pulmonary veins and pulmonary artery are separated
    • -lung removed
    • -bronchus of donor lung is connected to patient's bronchus
    • -Vessels connected
  26. Postoperative Management
    • -ICU
    • -ventilator
    • -drips to maintain tight control of hemodynamics and kidney function
    • -drainage tubes/catheters
    • -immunosuppression
  27. Early Complications
    • 1. Reperfusion pulmonary edema
    • 2. Primary graft failure
    • 3. Hemorrhage
    • 4. Bronchial dehiscence
    • -blood supply to bronchi is limited, and not anastamosed
    • -bronchial anastamoses are ischemic and can dehisce
    • 5. Non-infectious pleural space problems
    • -effusions
    • -pneumothorax
  28. Post Op Infections
    • -transplanted organs are exposed to external environment
    • -CMV
    • -PCP

    *Infection can trigger rejection

    Transbronchial bx and BAL to differentiate between infection and rejection
  29. Rejection
    • -routine screening
    • -lung allografts are more antigenic and more vulnerable to rejection

    • Symptoms:
    • -malaise
    • -SOB-lung infiltrate

    • Diagnosis:
    • -biopsy
    • -BAL
    • -serial daily spirometry (FEV1)
  30. Bronchiolitis Obliterans
    • -Primary factor limiting long-term survival
    • -etiology unknown
    • -most important cause of mortality and morbidity after lung transplant
    • -affects 50% of long term survival
    • -50% respond to enhanced immunosuppression
    • -some will have progressive deterioration of lung fxn
  31. Lung Transplant Survival
    • -Survival better after BLT
    • -Median Survival 5.3 years
    • -If patient survives past 1 year median survival goes up to 7.9 years

    • One year survival = 80%
    • Five year survival = 50%

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